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Health and Disability Commissioner • Response from Ms D to the Commissioner dated 24 January 2006, marked with an ‘F’. • Response from [the DHB] to the Commissioner dated 14 December 2005, marked with a ‘G’. • Copy of Oxytocin (Syntocinon) protocol from [the DHB], marked with an ‘H’. • Example of access agreement between obstetrician and [the DHB] from 1999, marked with an ‘I’. • Copy of [Mrs A’s] clinical notes and CTG tracings from 10 and 11 February 2001, marked with a ‘J’. • Neonatology report: [by a specialist neonatal paediatrician at the public hospital] OPINION [Dr B] attended [Mrs A] within a reasonable timeframe following her admission to the Delivery Suite on 10 February 2001 with spontaneous rupture of membranes pre labour. The initial clinical assessment was competent. Note was made that [Mrs A] was not in labour, she was afebrile, the uterus was of an appropriate size for full term and the presentation was cephalic and that the diagnosis of spontaneous rupture of membranes was confirmed and swabs taken. With regard to the initial management, [Mrs A] was offered two reasonable management options, namely 1. To watch and wait over the first 48 hours providing there was no change in the clinical parameters to give rise to concern but if labour did not commence spontaneously then for augmentation with syntocinon ± the use of prostaglandin gel. 2. To proceed immediately to augmentation (in fact it would have been induction — strictly defined) of labour. In my view a third option ought to have been offered, that being to proceed to Caesarean section on the grounds that the head was unengaged, the membranes had ruptured pre labour which is usually a bad prognostic sign with regard to orientation of the fetal head. The fact this option was not discussed can only be considered to be a minor issue as one would have to take into consideration the expectations of [Mr and Mrs A]. It may for example have been clear to [Dr B] that a trial of labour was the option that they wished to pursue and therefore only options regarding how such a trial ought to be conducted would therefore need to be detailed. With regard to the duration of the first stage of labour one can define labour as the onset of painful contractions associated with the observation of progressive dilatation of the cervix. Labour therefore by definition is a retrospective diagnosis and even the definition given only allows for a ‘best guess’ opinion, 10 19 September 2006 Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name
Opinion/05HDC16711 for example if one imagines an occipito-posterior presentation poorly applied to the cervix simply because of the head ill fitting in the pelvis then significant ‘labour’ contractions may occur without the cervix dilating. A long ‘latent’ phase of labour must always then be considered a warning sign for cephalopelvic disproportion be it absolute or relative relating to orientation of the fetal head. If contractions already seemed to be adequate then the use of syntocinon to augment the first stage would be questionable for fear of causing rupture of the lower segment of the uterus given the past history of Caesarean section. If contractions were considered to be inadequate (lack of cervical dilatation alone cannot be used to assess the adequacy or inadequacy because of the factors already mentioned above) then a cautious use of syntocinon after a full discussion with the woman concerned and other care givers is a reasonable option. […] I would state that the character of the first stage of labour was definitely dysfunctional due to slow progress and even after syntocinon was commenced along with epidural anaesthesia at 0500 hours on the 11.2.2001 progress thereafter still fell short of an accepted ‘normal’ rate of progress. This should be qualified by saying that providing [Mrs A] was still focused on achieving a vaginal delivery, providing she understood the risks of the use of syntocinon and providing the option of abandoning attempt at a vaginal delivery and proceeding to a Caesarean section was available then it was reasonable to continue as there was no evidence of a CTG abnormality until 1600 hours on 11.2.2001. At 1600 hours variable decelerations presented which gradually deteriorated in character up until the CTG tracings were discontinued at 1728. Variable decelerations, particularly if deep and wide, can be associated with fetal hypoxia. There is a high false positive diagnostic error rate, therefore if delivery is not imminent, fetal blood sampling is recommended as best practice. I therefore have concerns regarding the deteriorating CTG trace. My concerns are on three counts — 1. That the character of the variable decelerations was seen to gradually deteriorate up until the time that the CTG trace was discontinued at 1728. 2. That the tocograph portion of the CTG was discontinued at 1640, making it very difficult to time decelerations thereafter in respect to the uterine activity. Therefore if variable decelerations became consistently late decelerations one could possibly miss the association on clinical grounds alone. Late decelerations indicate a higher risk of fetal compromise/hypoxia but again there is still a high false positive rate from such recordings. 3. I am concerned that 52 minutes passes between the last cardio tocograph recording at 1728 and eventual delivery at 1820. I am particularly concerned that in [Dr B’s] report of 16 July (labelled ‘B’ in supporting information) a statement is made that at 1730 the CTG was noted to be okay. In my opinion the CTG was then abnormal (actually last recorded 1728). The decision to perform a ventouse delivery to conclude the second stage is reasonable providing the acoucher believes that the chance of success is high. Descent, rotation and delivery within four contractions would be considered to 19 September 2006 11 Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
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